COMMENTARY It’ s All About the Foot Pedal One Small Step for the Obstetric Sonographer, One Big Step for the Prenatal Detection of Congenital Heart Disease Mark S. Sklansky, MD, Gary M. Satou, MD, Greggory R. DeVore, MD D espite decades of technological advances, prenatal detec- tion rates for major forms of congenital heart disease (CHD) remain unacceptably low. 1–3 Even in the devel- oped world, where advanced, high-resolution ultrasound systems and transducers are most widely available, most cases of CHD continue to be missed at the time of the second-trimester anatomic survey. 1–3 The problem is not that current equipment cannot image ade- quately; the problem is that we, the sonographers, are not scan- ning properly. Although various components of the expanded fetal cardiac screening evaluation have received deserved emphasis and attention, we propose that two-handed scanning, using a foot pedal to store images/clips, may represent an important, addi- tional step for your practice to improve the acquisition of diagnos- tic images/clips and, thereby, to improve the detection of CHD. As screening for CHD relies on tomographic, 2-dimensional imaging, screening protocols appropriately include a series of planes to visualize important cardiac structures—principally the 4-chamber view, left and right ventricular outflow tracts, 4,5 and, increasingly, the 3-vessel tracheal view. 6 Simply put, what is not imaged cannot be screened. Abnormalities of function, and even some abnormalities of structure, require the heart to be evaluated as it contracts and relaxes during the cardiac cycle; evaluating still-frame images can- not consistently show anatomic abnormalities that may be present only at certain parts of the cycle and has limited ability to evaluate cardiac function. 7,8 Again, what is not imaged cannot be screened. Likewise, color flow Doppler imaging enables visualization of valvar dysfunction, areas of stenosis/obstruction, and septal defects that might otherwise not be visualized even with optimal tomographic, grayscale imaging. 9 Still again, what is not imaged (in this case, blood flow) cannot be screened. However, even adoption of the above approaches—the use of extended screening planes, storage of cardiac clips rather than still- frame images, and the inclusion of color flow Doppler imaging— will make limited improvements in prenatal detection without adequate image acquisition and appropriate angles of acquisi- tion. 10 Although the importance of training for specific views can- not be overemphasized, the importance of adequate image quality has been woefully neglected. Received June 4, 2018, from the Department of Pediatrics (M.S., G.S.); Department of Obstetrics and Gynecology (G.D.), David Geffen School of Medicine at UCLA, Los Angeles, California, USA. Manuscript ac- cepted for publication July 17, 2018. Address correspondence to Mark Sklans- ky, MD, UCLA Children’s Heart Center, 200 Medical Plaza, Suite 330, Los Angeles, CA 90095 USA. E-mail: msklansky@mednet.ucla.edu Abbreviations CHD, congenital heart disease doi:10.1002/jum.14784 © 2018 by the American Institute of Ultrasound in Medicine | J Ultrasound Med 2018; 00:1–3 | 0278-4297 | www.aium.org